- Email: [email protected]
Transrectal Ultrasound Guided Prostatic Nerve Blockade Eases Systematic Needle Biopsy of the Prostate
0022-5347/96/1552-0607$03.00/0 THEJOURNALOF UROLOGY Copyright 0 1996 by AMERICAN UROLGGICAL kssocunoN, INC.
Vol. 155.607-609. February 1996 Printed in U S A
TRANSRECTAL ULTRASOUND GUIDED PROSTATIC NERVE BLOCKADE EASES SYSTEMATIC NEEDLE BIOPSY OF THE PROSTATE PETER A. NASH, JEREMY E. BRUCE, RAMAIAH I N D U D W
AND
KATSUTO SHINOHARA*
From the Department of Urology, University of California School of Medicine, San Francisco, California
ABSTRACT
Purpose: We assessed the effect of transrectal ultrasound guided prostatic nerve blockade on the discomfort associated with systematic needle biopsy of the prostate. Materials and Methods: A prospective randomized double-blind study was performed of 64 patients requiring systematic biopsy of the prostate. Patients were randomly assigned to receive an injection of 5 ml. 1%lidocaine or 5 ml. saline (0.9% sodium chloride) at the vascular pedicle on 1 side of the prostate only. They were then asked to score the severity of discomfort of the injection and subsequent biopsies on each side. Results: Mean pain scores were sigmfkantly lower on the side with than the side without lidocaine injection (1.6t 0.9 versus 2.4 2 1.2, p <0.0001) and not significantly M e r e n t when saline was injected (2.9 t 1.2 versus 3.0 -+ 1.1,p = 0.52). Pain scores were significantly different when the lidocaine injected side was compared to the saline solution injected side (p <0.0001)but the difference was not significant between the noninjected sides of the 2 groups (p = 0.076). Of the patients in the lidocaine group 68%reported that they would prefer to undergo biopsy with the injection compared to only 41% in the placebo group (p = 0.037). During the study no patient in either group had any adverse effect from the injection. Conclusions: Transrectal ultrasound guided nerve blockade before prostatic biopsy results in a more comfortable procedure for the patient. Kcr WORDS: prostate; anesthesia, local; ultrasonography;biopsy
During transrectal ultrasound guided systematic needle 1%lidocaine or 5 ml. saline (0.9% sodium chloride). The side biopsy of the prostate 65 to 90% of patients reportedly have of injection was alternated in each patient. Injections were done via a 7-inch 22 gauge spinal needle discomfort'-2 but few studies have investigated how to minimize discomfort. We recently developed the technique of under ultrasound guidance into the region of the prostatic transrectal ultrasound guided prostatic nerve blockade be- vascular pedicle at the base of the prostate just lateral to the fore systematic needle biopsy, and it has been our impression junction between the prostate and seminal vesicle (fig. 1). that patients were considerably more comfortable during biopsy when this procedure was done beforehand. To assess this observation objectively we performed a prospective randomized double-blind study of the effect of transrectal ultrasound guided prostatic nerve blockade on the discomfort associated with systematic needle biopsy of the prostate. PATIENTS AND METHODS
Approval for this study was obtained from the Committee on Human Research at our university. Patients referred for transrectal ultrasound from whom informed consent was obtained were eligible for inclusion into the study. Patients who had a bleeding diathesis, were receiving anticoagulation therapy or were suspected of having a urological infection Were excluded from the study. All transrectal ultrasound guided prostatic biopsies were performed by 1of us (K. S.) on an outpatient basis. Patients received 1Fleet enema and 500 mg. ciprofloxacin or 160/180 mg. trimethoprim-sulfamethoxazole 1hour before the procedure with the antibiotic repeated 3 times every 12 hours thereafter. Patients were examined in the leR lateral decubitus position with a Siemens Sonoline SI-25Ot biplanar variable frequency (5 to 7.5 MHz.) probe. The 64 patients m ~ ing systematic biopsy of the prostate were randomly assigned to receive a unilateral injection of a sterile solution of 5 ml.
-
Accepted for publication August 11, 1995. F'Ic. 1. Ultrasound probe in situ and spinal needle placement * Reyes,ts for Department of Urology, U-575, University within neurovascular bundle at base of prostate just lateral to juncof Cali o m a , San anasco, California 941434738. tion between prostate and sermnal vesicle. t Siemens Medical Systems, Inc., Issaquab, WasKnpton. 607
regne:
608
PROSTATIC NERVE BLOCKADE FOR NEEDLE BIOPSY
The syringe was aspirated before injection to ensure t h a t the vascular system had not been entered, and the separation of tissue planes caused by the injection was confirmed by ultrasound monitoring (fig. 2 ) . After a 5-minute interval systematic biopsy of the prostate was performed with a n 18 gauge biopsy needle fired by a spring action biopsy gun. At the conclusion of the procedure patients were interviewed by 1 of us (P. A. N. or R. 1.1 who was blinded to the injected solution. Patients were asked to score the severity of discomfort of the injection and biopsies on each side a s 1-no pain, 2-slight pain, 3-moderate pain. 4-severe pain and 5-intolerable pain. Patient preference for systematic biopsy with or without pre-biopsy unilateral injection was noted. Patient age. prostate volume, prostate specific antigen (PSA) level and any side effects were also recorded. Prostate volume was determined with the prolated ellipsoid method. PSA levels were determined with the Abbott IMx assay. The Student t, Mann-Whitney U and chi-square tests were used for comparison of data.
Mean age, prostatic ilolunie and PSA rialue in 64 patients 15 Lidocaine 0.95 Sodium Chloride p \'a!~~
No pts. Age 1 1 ~ s1 . Prostate vul. I c c ~
PSA (ng./ml.) __-
34 66.6 47.7 11.3 -
~~
30 66.9 55.7 26.8
~
~~
0 x5 0 51 0.3ti ~~~
-
-
DISC'LISSION
In 1963 Takahashi and Ouchi first performed transrectal ultrasonography to scan t h e prostate,:' and in 1981 Holm and Gammelgaard described transperineal biopsy of t h e prostate guided by transrectal ultrasound.4 However, patient compliance was low because of the discomfort associated with biopsy through such a sensitive area. In 1989 Torp-Pedersen e t al reported the results of transrectal ultrasound guided biopsy of the prostate with a n 18 gauge needle loaded in a spring action biopsy device.5 This method resulted in improved patient tolerance because of the relative insensitivity of the rectal wall and rapid firing of t h e thin needle by a n RESL'LTS automatic device. During a 3-month period 6 4 patients were randomized into In our experience a significant proportion of patients una study arm (34 lidocaine and 30 saline). Patients underwent dergoing transrectal ultrasound guided prostatic biopsy still an equal number of biopsies on each side of the prostate find the procedure uncomfortable and discomfort appears to (mean 3.1 biopsies per side, range 2 to 6 ) and 9 2 4 underwent be proportional to the number of biopsies performed. In 2 3 or more biopsies bilaterally. Each group was well matched recent reviews of transrectal ultrasound guided biopsy of the for patient age, prostate volume and PSA level (see table). In prostate between 65% and 90% of patients reported discompatients who received a unilateral injection of lidocaine mean fort.1.2 In an attempt to alleviate this discomfort we have pain scores were significantly lower on the lidocaine injected developed a technique of transrectal ultrasound guided prosthan noninjected side (1.6 2 0.9 versus 2.4 -t 1.2, p <0.0001). tatic nerve blockade with a 1%lidocaine solution before biHowever, in patients who received a unilateral injection of saline solution the difference in discomfort on the injected opsy. Pain associated with prostate biopsy predominantly arises and noninjected sides was not significant (2.9 ? 1.2 versus in the prostatic capsule or stroma, where there is a rich 3.0 f 1.1, p = 0.52). innervation of autonomic fibers. These autonomic nerves conMean pain scores on the injected sides for the lidocaine and vey visceral sensation to the spinal cord. The innervation of saline groups were significantly different (1.6 -t 0.9 and 2.9 t the prostate is derived from the caudal roots of S2 to 5 and 1.2, respectively, p <0.0001). However, on the noninjected t h e sympathetic chain via the presacral and hypogastric neusides t.he difference between the groups was not significant ( p ral plexuses. These fibers ramify in t h e prostatic plexus and = 0.076) although mean pain scores were lower in patients subsequently travel with t h e prostatic vascular pedicles, who received lidocaine on the contralateral side (2.4 2 1.2 which are located at the posterolateral aspect of t h e prostatic versus 3.0 2 1.1). When patients were asked whether they base. In 1990 Reddy described a technique of transperineal preferred to undergo prostatic biopsy with the nerve block, prostatic nerve blockade i n which local anesthesia is injected 68% who received lidocaine responded affirmatively com- along the lateral edge of t h e prostate, and the junction of the pared to only 41% who received the placebo ( p = 0.05). prostate and seminal vesicle.6 However, with transrectal inThroughout the study period no patient in either group had jection the entire gland can be anesthetized by 1 injection at any adverse effect from injection. the vascular pedicle of t h e prostatic base without moving the patient after he is placed in the lateral decubitus position for biopsy. Transrectal ultrasound monitoring also facilitates correct localization of the needle and confirms t h a t anesthesia is infiltrating t h e correct plane. In our prospective randomized placebo-controlled study of this technique we found that patients receiving a unilateral prostatic nerve blockade with lidocaine had pain scores t h a t were significantly lower on the injected than noninjected side, and also significantly lower t h a n in patients receiving saline solution. On t h e noninjected sides pain scores were lower in patients injected with lidocaine on the contralateral side although this difference was not statistically significant ( p = 0.076). In our small sample this trend may be the result of bilateral innervation. Importantly significantly more patients stated their preference for transrectal ultrasound guided prostatic biopsy after nerve blockade. Throughout the study period no adverse effects were recorded in either group. Specifically no infective complications developed and no patient complained of dizziness, tinnitus, visual disturbances or allergic reaction associated with inadvertent intravascular injection of lidocaine. FIG.2. Ultrasound shows sagittal section of base of prostate (PI. Syringe aspiration before injection and confirmation of the separation of tissue planes on ultrasonography a r e important After injection of 5 ml. lr4 hdocaine hypoechoic space is created at injection site h arrow^. SV, seminal vesicle. steps in avoiding this complication.
PROSTATIC NERVE BLOCKADE FOR NEEDLE BIOPSY CONCLUSIONS
We believe that transrectal ultrasound guided prostatic nerve blockade before biopsy diminishes the discomfort associated with the procedure, improving patient tolerance. By eliminating undue patient movement and because of the ease of obtaining multiple tissue cores, biopsy of digital and sonographic abnormalities may be more accurate. This procedure is well tolerated and adds no significant morbidity to prostate biopsy. Our technique of prostatic anesthesia may be applicable to other prostatic procedures, such as laser or focused ultrasound ablation. REFERENCES
1. Clements, R., Aideyan, 0. U., Griffiths, G. J. and Peeling, W. B.: Side effects and patient acceptability of transrectal biopsy of the prostate. Clin. Rad., 47: 125,1993.
609
2. Collins, G. N., Lloyd, S. N., Hehir. M. and McKelvie. G.
B.:
Multiple transrectal ultrasound-guided prostatic biopaieatrue morbidity and patient acceptance. Brit. J. Uml., 71: 460. 1993.
3. Takahashi, H. and Ouchi, T.: The ultnwnic diagnosis in the field of urology (the first report). Proc. Jap. Soc. Ultrasonics Med., 3 7,1963. 4. Holm, H. H. and Gammelgaard, J.: Ultrasonically guided precise needle placement in the prostate and the seminal vesicles. J. Urol., 126: 385. 1981. 5. Torp-Pedereen, S., Lee. F., Littrup, P. J.. Sidere, D. B.. Kumasaka, G. H., Solomon, M. H. and McLeary, R.D.: Transrectal biopsy of the prostate guided with transrectal US: longitudinal and multiplanar scanning. Radiology, 170: 23, 1989. 6. Reddy, P. K.: New technique to anesthetize the prostate for transurethral balloon dilation. Urol. Clin. N. Amer., 17: 65, 1990.
Vol. 155.607-609. February 1996 Printed in U S A
TRANSRECTAL ULTRASOUND GUIDED PROSTATIC NERVE BLOCKADE EASES SYSTEMATIC NEEDLE BIOPSY OF THE PROSTATE PETER A. NASH, JEREMY E. BRUCE, RAMAIAH I N D U D W
AND
KATSUTO SHINOHARA*
From the Department of Urology, University of California School of Medicine, San Francisco, California
ABSTRACT
Purpose: We assessed the effect of transrectal ultrasound guided prostatic nerve blockade on the discomfort associated with systematic needle biopsy of the prostate. Materials and Methods: A prospective randomized double-blind study was performed of 64 patients requiring systematic biopsy of the prostate. Patients were randomly assigned to receive an injection of 5 ml. 1%lidocaine or 5 ml. saline (0.9% sodium chloride) at the vascular pedicle on 1 side of the prostate only. They were then asked to score the severity of discomfort of the injection and subsequent biopsies on each side. Results: Mean pain scores were sigmfkantly lower on the side with than the side without lidocaine injection (1.6t 0.9 versus 2.4 2 1.2, p <0.0001) and not significantly M e r e n t when saline was injected (2.9 t 1.2 versus 3.0 -+ 1.1,p = 0.52). Pain scores were significantly different when the lidocaine injected side was compared to the saline solution injected side (p <0.0001)but the difference was not significant between the noninjected sides of the 2 groups (p = 0.076). Of the patients in the lidocaine group 68%reported that they would prefer to undergo biopsy with the injection compared to only 41% in the placebo group (p = 0.037). During the study no patient in either group had any adverse effect from the injection. Conclusions: Transrectal ultrasound guided nerve blockade before prostatic biopsy results in a more comfortable procedure for the patient. Kcr WORDS: prostate; anesthesia, local; ultrasonography;biopsy
During transrectal ultrasound guided systematic needle 1%lidocaine or 5 ml. saline (0.9% sodium chloride). The side biopsy of the prostate 65 to 90% of patients reportedly have of injection was alternated in each patient. Injections were done via a 7-inch 22 gauge spinal needle discomfort'-2 but few studies have investigated how to minimize discomfort. We recently developed the technique of under ultrasound guidance into the region of the prostatic transrectal ultrasound guided prostatic nerve blockade be- vascular pedicle at the base of the prostate just lateral to the fore systematic needle biopsy, and it has been our impression junction between the prostate and seminal vesicle (fig. 1). that patients were considerably more comfortable during biopsy when this procedure was done beforehand. To assess this observation objectively we performed a prospective randomized double-blind study of the effect of transrectal ultrasound guided prostatic nerve blockade on the discomfort associated with systematic needle biopsy of the prostate. PATIENTS AND METHODS
Approval for this study was obtained from the Committee on Human Research at our university. Patients referred for transrectal ultrasound from whom informed consent was obtained were eligible for inclusion into the study. Patients who had a bleeding diathesis, were receiving anticoagulation therapy or were suspected of having a urological infection Were excluded from the study. All transrectal ultrasound guided prostatic biopsies were performed by 1of us (K. S.) on an outpatient basis. Patients received 1Fleet enema and 500 mg. ciprofloxacin or 160/180 mg. trimethoprim-sulfamethoxazole 1hour before the procedure with the antibiotic repeated 3 times every 12 hours thereafter. Patients were examined in the leR lateral decubitus position with a Siemens Sonoline SI-25Ot biplanar variable frequency (5 to 7.5 MHz.) probe. The 64 patients m ~ ing systematic biopsy of the prostate were randomly assigned to receive a unilateral injection of a sterile solution of 5 ml.
-
Accepted for publication August 11, 1995. F'Ic. 1. Ultrasound probe in situ and spinal needle placement * Reyes,ts for Department of Urology, U-575, University within neurovascular bundle at base of prostate just lateral to juncof Cali o m a , San anasco, California 941434738. tion between prostate and sermnal vesicle. t Siemens Medical Systems, Inc., Issaquab, WasKnpton. 607
regne:
608
PROSTATIC NERVE BLOCKADE FOR NEEDLE BIOPSY
The syringe was aspirated before injection to ensure t h a t the vascular system had not been entered, and the separation of tissue planes caused by the injection was confirmed by ultrasound monitoring (fig. 2 ) . After a 5-minute interval systematic biopsy of the prostate was performed with a n 18 gauge biopsy needle fired by a spring action biopsy gun. At the conclusion of the procedure patients were interviewed by 1 of us (P. A. N. or R. 1.1 who was blinded to the injected solution. Patients were asked to score the severity of discomfort of the injection and biopsies on each side a s 1-no pain, 2-slight pain, 3-moderate pain. 4-severe pain and 5-intolerable pain. Patient preference for systematic biopsy with or without pre-biopsy unilateral injection was noted. Patient age. prostate volume, prostate specific antigen (PSA) level and any side effects were also recorded. Prostate volume was determined with the prolated ellipsoid method. PSA levels were determined with the Abbott IMx assay. The Student t, Mann-Whitney U and chi-square tests were used for comparison of data.
Mean age, prostatic ilolunie and PSA rialue in 64 patients 15 Lidocaine 0.95 Sodium Chloride p \'a!~~
No pts. Age 1 1 ~ s1 . Prostate vul. I c c ~
PSA (ng./ml.) __-
34 66.6 47.7 11.3 -
~~
30 66.9 55.7 26.8
~
~~
0 x5 0 51 0.3ti ~~~
-
-
DISC'LISSION
In 1963 Takahashi and Ouchi first performed transrectal ultrasonography to scan t h e prostate,:' and in 1981 Holm and Gammelgaard described transperineal biopsy of t h e prostate guided by transrectal ultrasound.4 However, patient compliance was low because of the discomfort associated with biopsy through such a sensitive area. In 1989 Torp-Pedersen e t al reported the results of transrectal ultrasound guided biopsy of the prostate with a n 18 gauge needle loaded in a spring action biopsy device.5 This method resulted in improved patient tolerance because of the relative insensitivity of the rectal wall and rapid firing of t h e thin needle by a n RESL'LTS automatic device. During a 3-month period 6 4 patients were randomized into In our experience a significant proportion of patients una study arm (34 lidocaine and 30 saline). Patients underwent dergoing transrectal ultrasound guided prostatic biopsy still an equal number of biopsies on each side of the prostate find the procedure uncomfortable and discomfort appears to (mean 3.1 biopsies per side, range 2 to 6 ) and 9 2 4 underwent be proportional to the number of biopsies performed. In 2 3 or more biopsies bilaterally. Each group was well matched recent reviews of transrectal ultrasound guided biopsy of the for patient age, prostate volume and PSA level (see table). In prostate between 65% and 90% of patients reported discompatients who received a unilateral injection of lidocaine mean fort.1.2 In an attempt to alleviate this discomfort we have pain scores were significantly lower on the lidocaine injected developed a technique of transrectal ultrasound guided prosthan noninjected side (1.6 2 0.9 versus 2.4 -t 1.2, p <0.0001). tatic nerve blockade with a 1%lidocaine solution before biHowever, in patients who received a unilateral injection of saline solution the difference in discomfort on the injected opsy. Pain associated with prostate biopsy predominantly arises and noninjected sides was not significant (2.9 ? 1.2 versus in the prostatic capsule or stroma, where there is a rich 3.0 f 1.1, p = 0.52). innervation of autonomic fibers. These autonomic nerves conMean pain scores on the injected sides for the lidocaine and vey visceral sensation to the spinal cord. The innervation of saline groups were significantly different (1.6 -t 0.9 and 2.9 t the prostate is derived from the caudal roots of S2 to 5 and 1.2, respectively, p <0.0001). However, on the noninjected t h e sympathetic chain via the presacral and hypogastric neusides t.he difference between the groups was not significant ( p ral plexuses. These fibers ramify in t h e prostatic plexus and = 0.076) although mean pain scores were lower in patients subsequently travel with t h e prostatic vascular pedicles, who received lidocaine on the contralateral side (2.4 2 1.2 which are located at the posterolateral aspect of t h e prostatic versus 3.0 2 1.1). When patients were asked whether they base. In 1990 Reddy described a technique of transperineal preferred to undergo prostatic biopsy with the nerve block, prostatic nerve blockade i n which local anesthesia is injected 68% who received lidocaine responded affirmatively com- along the lateral edge of t h e prostate, and the junction of the pared to only 41% who received the placebo ( p = 0.05). prostate and seminal vesicle.6 However, with transrectal inThroughout the study period no patient in either group had jection the entire gland can be anesthetized by 1 injection at any adverse effect from injection. the vascular pedicle of t h e prostatic base without moving the patient after he is placed in the lateral decubitus position for biopsy. Transrectal ultrasound monitoring also facilitates correct localization of the needle and confirms t h a t anesthesia is infiltrating t h e correct plane. In our prospective randomized placebo-controlled study of this technique we found that patients receiving a unilateral prostatic nerve blockade with lidocaine had pain scores t h a t were significantly lower on the injected than noninjected side, and also significantly lower t h a n in patients receiving saline solution. On t h e noninjected sides pain scores were lower in patients injected with lidocaine on the contralateral side although this difference was not statistically significant ( p = 0.076). In our small sample this trend may be the result of bilateral innervation. Importantly significantly more patients stated their preference for transrectal ultrasound guided prostatic biopsy after nerve blockade. Throughout the study period no adverse effects were recorded in either group. Specifically no infective complications developed and no patient complained of dizziness, tinnitus, visual disturbances or allergic reaction associated with inadvertent intravascular injection of lidocaine. FIG.2. Ultrasound shows sagittal section of base of prostate (PI. Syringe aspiration before injection and confirmation of the separation of tissue planes on ultrasonography a r e important After injection of 5 ml. lr4 hdocaine hypoechoic space is created at injection site h arrow^. SV, seminal vesicle. steps in avoiding this complication.
PROSTATIC NERVE BLOCKADE FOR NEEDLE BIOPSY CONCLUSIONS
We believe that transrectal ultrasound guided prostatic nerve blockade before biopsy diminishes the discomfort associated with the procedure, improving patient tolerance. By eliminating undue patient movement and because of the ease of obtaining multiple tissue cores, biopsy of digital and sonographic abnormalities may be more accurate. This procedure is well tolerated and adds no significant morbidity to prostate biopsy. Our technique of prostatic anesthesia may be applicable to other prostatic procedures, such as laser or focused ultrasound ablation. REFERENCES
1. Clements, R., Aideyan, 0. U., Griffiths, G. J. and Peeling, W. B.: Side effects and patient acceptability of transrectal biopsy of the prostate. Clin. Rad., 47: 125,1993.
609
2. Collins, G. N., Lloyd, S. N., Hehir. M. and McKelvie. G.
B.:
Multiple transrectal ultrasound-guided prostatic biopaieatrue morbidity and patient acceptance. Brit. J. Uml., 71: 460. 1993.
3. Takahashi, H. and Ouchi, T.: The ultnwnic diagnosis in the field of urology (the first report). Proc. Jap. Soc. Ultrasonics Med., 3 7,1963. 4. Holm, H. H. and Gammelgaard, J.: Ultrasonically guided precise needle placement in the prostate and the seminal vesicles. J. Urol., 126: 385. 1981. 5. Torp-Pedereen, S., Lee. F., Littrup, P. J.. Sidere, D. B.. Kumasaka, G. H., Solomon, M. H. and McLeary, R.D.: Transrectal biopsy of the prostate guided with transrectal US: longitudinal and multiplanar scanning. Radiology, 170: 23, 1989. 6. Reddy, P. K.: New technique to anesthetize the prostate for transurethral balloon dilation. Urol. Clin. N. Amer., 17: 65, 1990.